Relating to risk : sexual behaviour and risk perception among men who have sex with men

Background: Men who have sex with men (MSM) are a key population for HIV worldwide. Overall HIV incidence is declining but over the past years the proportion of HIV diagnoses attributed to sex between men has remained high in Europe. MSM account for 40% of the reported HIV diagnoses in Europe (2016) and more than 47% in Sweden (cases reported transmitted in Sweden, 2017) despite the notion that HIV is preventable through treatment and effective public health measures. A matrix of social, legal, biological, epidemiological and behavioural causes contribute to the disproportionate vulnerability for HIV infection among MSM in general and to greater extent among certain sub-groups of MSM. Aim: The overall aim of this thesis is to explore and analyse risk factors and risk behaviour for HIV transmission among MSM. Methods: This research project employed quantitative (I-III) and qualitative (V) methods. Studies I-III were undertaken in Sweden and based on data collected with stratified sampling among men in a web community for LGBT persons. The cross-sectional survey, MSM2013, reached 2 751 MSM residing in Sweden. Study IV was based on semi-structured in-depth interviews with 15 MSM recruited through respondent driven sampling and analysed with content analysis. Results: In study I, a weighted Latent Class Analysis with covariates and distal outcomes was conducted to identify four sub-groups of MSM sharing similar sexual practice characteristics: experimentals, bottoms, riskreducers and clubbers. Experimentals clearly stood out from the other classes with its broad sexual repertoire and high self-rated HIV preventive knowledge. In study II, we found that many MSM (40%) test for HIV regularly and that outreach and promoting initiatives contribute to testing. Still, factor analysis revealed that fear, anxiety, low risk perception and inaccessible test services remain barriers for testing. In study III and IV, we concluded that MSM of different HIV status meet in gay-oriented venues both in their home countries and when travelling abroad. We documented that MSM having anal intercourse without condom with casual partners abroad are high sexual risk-takers with broad sexual repertoire. The in-depth interviews in study IV captured a priority target group for HIV prevention: a highly mobile and highly sexually active subgroup of MSM with high HIV and STI risk taking behaviour regardless of context. Berlin provides venues and spaces for sexual liberation greatly appreciated by this subgroup of MSM. Conclusions: This thesis has shown that the diversity among MSM, based on similar sexual practice patterns, should be considered when designing HIV preventive interventions. The finding, that sub-groups of MSM have different sexual practice patterns can provide a base for screening-instruments, medical and behavioural history forms and counselling guides within healthcare and social work, as well as a base for allocation of resources for prevention. This thesis has also highlighted that preventive interventions focusing solely on increasing knowledge may not be an effective method to reach and decrease HIV risk behaviour among MSM with broad sexual repertoire and high numbers of sex partners. These men may specifically benefit from a HIV and STI testing routine that includes counselling. Healthcare professionals providing care for MSM who test for HIV regularly should remember that this group is reachable and a priority for HIV preventive interventions. Healthcare professionals and prevention workers meeting MSM should have MSM competency and be comfortable and competent to deliver easily accessible test services, including outreach test promotion/testing. Within HIV prevention and HIV test promotion in settings where MSM from different countries and contexts meet there is a need to further prioritise a needs-based approach to risk reduction measures